Healthcare Provider Details

I. General information

NPI: 1609853688
Provider Name (Legal Business Name): SOUTH COUNTIES PEDIATRIC CRITICAL CARE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17100 EUCLID ST ATTN: PICU
FOUNTAIN VALLEY CA
92708-4004
US

IV. Provider business mailing address

17100 EUCLID ST ATTN: PICU
FOUNTAIN VALLEY CA
92708-4004
US

V. Phone/Fax

Practice location:
  • Phone: 714-966-7253
  • Fax:
Mailing address:
  • Phone: 714-966-7253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ZACHARIA REDA
Title or Position: PRESIDENT
Credential: MD
Phone: 714-966-7253